The War Against Tuberculosis IN SAN FRANCISCO "It is within the power of man to cause all parasitic diseases to disappear from the world.". — Pasteur Published by San Francisco Tuberculosis Association SAN FRANCISCO, CALIFORNIA 1928 <*HPHE importance of the crusade against tubercu- losis cannot be overestimated. Science has dem- onstrated that this disease can be stamped out, but the rapidity and completeness with which this can be accomplished depend upon the promptness with which the new doctrines about tuberculosis can be inculcated into the minds of the people and engrafted upon our customs, habits, and laws. The modern crusade against tuberculosis brings hope and bright prospects of recovery to hundreds and thousands of victims of the disease, who under old teachings were abandoned to despair." — Theodore Roosevelt. San Francisco Tuberculosis Association Organized June 25, 1908, as The San Francisco Association for the Study and Prevention of Tuberculosis. OFFICERS John S. Drum, President George S. Hollis, Vice-President William H. Crocker, Treasurer Dr. William C. Voorsanger, Secretary DIRECTORS AND EXECUTIVE COUNCIL MEMBERS Dr. Mariana Bertola Dr. Philip King Brown Dr. W. R. P. Clark Mrs. William H. Crocker Rev. C. S. S. Dutton Mrs. Alice S. Ellinwood Mrs. Milton Esberg Dr. George H. Evans Dr. Harold K. Faber Alexander Fleisher Will J. French Dr. Morton R. Gibbons Archbishop Edward J. Hanna Franck R. Havenner Mrs. I. W. Hellman William F. Higby Dr. William J. Kerr Dr. Alson R. Kilgore Dr. William P. Lucas Mrs. Parker S. Maddux Dr. Sidney J. Shipman Mrs. Joseph Sloss Mrs. George B. Somers Office— -20 SECOND STREET Telephone Sutter 1534 General Secretary, Paul Neiman FOREWORD "P OR more than twenty years it has been the constant endeavor of the San Francisco Tuberculosis Association to bring to bear against tuberculosis every influence that works toward reduction of the disease. Tuberculosis used to kill each year between 300 and 330 persons from every 100,000 living in San Francisco. Now it kills each year about 100 from every 100,000. Despite this great reduction tuberculosis still kills in San Francisco more persons in early adult life than are killed by any other disease. It still causes more suffering, more poverty and more dependency than any other disease. United public effort for its control and prevention must be continued and increased. It is true economy to provide public funds for hospitalization of those who have tuberculosis and lack the means to provide for themselves, and for such other public health activities as will accelerate the decline of this terrible and costly disease and eventu- ally wipe it out. Many thousands of persons have helped the Association in its work. Newspapers, public officials, churches, clubs, labor unions, lodges and other groups and individuals have aided the Association in such number, and so frequently, that it is impossible here to record their names but grateful acknowledgment is made to all. This booklet is published to review some of the things that have been done, to call attention to important changes that have taken place and to stimulate public interest in measures for further reduction of a preventable disease and the heavy economic loss that it causes. The Wide Extent and Great Cost of a Preventable Disease UEW persons realize how much tu- berculosis there is in large cities. Few realize how much it costs a city. In San Fran- cisco, as in nearly all cities, tuberculosis kills more per- sons in early adult life than any other disease. It is the greatest single cause of pov- erty and dependency. In San Francisco, of every ten beds provided by the tax- payers for the sick poor at the municipal hospital, four beds are for victims of tuber- culosis and six beds for the victims of all other ailments combined. The chart on this page shows how the days of free hospital care were di- vided in the fiscal year that ended June 30, 1928. Averaged, 875 beds were occupied by patients every day Days of free bed care provided for patients at San Francisco's munici- pal hospital in the twelve months ended June 30, 1928: 1. TUBERCULOSIS 122,748 2. General Medicine 60,129 3. Surgery 50,878 4. Isolation 20,162 5. Children's Department .... 17,686 6. Diseases of Women 13,421 7. Genito-Urinary 12,023 8. Maternity _ 6,885 9. Eye, Ear, Nose, Throat.. 5,376 10. Venereal 5,333 11. Nervous and Mental 4,727 Total 319,368 of the year. Of these, 336 were oc- cupied by tuberculosis patients and 539 by all other patients. Despite the large proportion of beds provided for tuberculosis pa- tients there is almost continuously a waiting list, as there is for nearly all departments of the hospital because of the recent great growth of San Francisco. At times recently as many as 290 tuberculosis patients have been cared for in hospital space built for 250. The long time that must pass be- fore tuberculosis is cured, or before it kills, is one reason why such a large part of the free bed care provided at public expense is required for the vic- tims of this one disease. The foregoing figures have to do only with bed care inside hospital walls. Throughout the year more than 2000 persons with tuberculosis, or believed in danger of getting it, were under free medical and nursing supervision at clinics and in their own homes. More than half were children less than 16 years old. Tuberculosis, al- though a prevent- able and curable disease, and al- though it has been greatly reduced, still kills about 600 persons in San Francisco every year. This toll is taken principally from among per- sons between 20 and 50 years of age. Ibisbi The chart illustrates the distribution of deaths by 10-year age groups. It is drawn from the average of the last five years. The variation in any one year from any of the group averages is not great, for tuberculosis is a re- markably steady and consistent killer. AVERAGE NUMBER OF TUBERCULOSIS DEATHS PER YEAR IN SAN FRANCISCO FOR THE LAST FIVE YEARS, BY 10-YEAR AGE GROUPS- "der in 20 30 40 to to 39 49 50 60 o»er 59 70 Note on the chart that tuberculosis kills most of its victims in their twen- ties. Note that it kills not the aged, who have lived out man's allotted span of years, but those on the thresh- old and in the prime of life. Tuber- culosis, like war, kills off the young men. It kills twice as many men as women in San Francisco. A few other diseases kill a greater number of persons, but they kill prin- cipally among the aged. In San Fran- cisco, diseases of the heart kill about twice as many persons as tuberculosis, but those killed by heart diseases are nearly all well along in years. Almost half are past 70 years of age. Tuberculosis causes a vast amount of poverty and dependency not only because it kills great numbers of young men who leave children not yet old enough to be self-supporting, but also because it is a long-drawn-out disease, causing complete disability of the wage-earners in many families for months and years at a time. "Approximately 33 per cent of all relief work is for families in which tuberculosis is the main if not the only cause of dependency. Forty-one per cent of the relief for widows given by the city is in families where tubercu- losis caused the husband's death. Of the money spent for child welfare, in 42 per cent it was the death of the father from tuberculosis that caused the dependency of the children. About one-half of the entire cost of the relief work of the city's principal charity agency is due to needs, in families and among individuals, created by tuber- culosis/' The foregoing quotation relates to New York City. Comparable per- centages for San Francisco are not available but would doubtless equal or exceed those of New York, for San Francisco's death rate from tubercu- losis has always been much higher than New York's. Medical authorities estimate that for each death yearly from tubercu- losis in a community there are seven living persons with the disease in such condition that medical and nursing supervision and care are needed. If this estimate is correct, there are in San Francisco all the time more than 4,000 persons seriously sick with tu- berculosis. Medical authorities also estimate that tuberculosis lasts, on an average, five years. Ordinarily among the cases that end fatally death is preceded by a long period of complete disability. This is estimated by some authorities to average 2]/z years, and by others 3 years. Complete cure, also, must generally be preceded by months and years of inactivity. It is not so difficult to cure tubercu- losis if the disease is discovered near the time of its beginning and sanator- ium care is provided, or home care under competent medical and nursing supervision. Unfortunately the dis- ease is too seldom discovered early, and too often it is impossible to pro- vide sanatorium care or to arrange home conditions suitable for cure. Tuberculosis is unlike many dan- gerous communicable diseases. It does not suddenly make violent attack on a community and then subside into a long period of inactivity. It kills at a comparatively even rate all the time, year after year, month after month. Persons do not generally realize the full extent of tuberculosis, the great loss it causes, and the need for large public expenditures to combat it, be- cause it is not a sudden or spectacular killer. It does not flare up in out- breaks like bubonic plague, or small- pox, or typhoid, or influenza, that arouse public alarm and public de- mand for prompt defensive measures. And yet tuberculosis kills many more than are killed by these other four plagues combined. In 1907 bubonic plague broke out in San Francisco. Private citizens, city, state and federal officials promptly combined to fight it. Laws to aid in control and prevention of the plague were passed. Public funds were ap- propriated liberally. By popular sub- scriptions $152,000 was added to the appropriations. Within a few months, by an expenditure of $585,000, the plague was checked. In 1907 the plague killed only 89 persons in the whole United States, and it has never since killed more than 30 in any one year in the United States. A Census Bureau report says : "Those 89 deaths in 1907 probably occasioned greater alarm than would be felt if tuberculosis caused 10,000 more deaths than usual." As the result of that public alarm, prompt and far-reaching action was taken. Thanks to the continued vigi- lance of federal, state and local health officials the plague has killed only a few more than 100 persons in the whole United States in the last 20 years. In the same 20 years tubercu- losis, although gradually declining, has killed more than 2,000,000 persons, more than 100,000 per year. Since 1908 only three persons have died of plague in San Francisco. Yet tuberculosis, "the white plague," which also to a large extent could be controlled and prevented, has killed more than 15,000 persons in San Francisco in that time. That last outbreak of bubonic plague in San Francisco in 1907 and 1908 killed 77 persons. In the same years the white plague killed more than 800 persons each year, but no one was sufficiently alarmed to do anything about it except a small group of persons who were organizing "an association for the study and preven- tion of tuberculosis" and preparing to open San Francisco's first tuberculosis clinic for the sick poor. When one considers, then, the large number of persons who have tubercu- losis, the difficulty of early discovery, the long time required to overcome the disease once it has gained a strong foothold, as it usually has before it is discovered, and that its victims are principally persons in early adult life, it is easier to understand why tuber- culosis is by far the most costly of all diseases to a community and why large expenditures of public money must be made to control and pre- vent it. TUBERCULOSIS DEATHS IN SAN FRANCISCO DIVIDED INTO 10- YEAR Ages Under 10 10-19 1923 54 36 1924 38 37 1925 38 39 1926 39 44 1927 45 31 Annual Average 42 37 AGE GROUPS 20-29 30-39 40-49 50-59 60-69 Over 70 Total 132 148 126 145 146 139 128 126 124 126 109 122 148 151 140 103 107 129 89 84 82 86 84 8 5 67 51 70 51 58 59 13 26 25 17 13 18 667 661 644 611 593 635 History of the Early Efforts to Check Tuberculosis in San Francisco FOR years prior to 1906 San Fran- *"■ cisco had the highest tuberculosis death rate, by far, of America's ten largest cities, but no attempt was made to do anything about it. There was widespread and deeply rooted belief that "consumption" was a calamity about which nothing could be done, and that the less said about it the better. Early in 1906 the first steps were taken toward control and prevention of the disease. A few physicians and other persons who believed something might be done toward reducing the loss of nearly 100 persons in early adult life every month, year after year, and who believed that public action should be taken toward ameliorating the hard lot of the many persons dis- abled and impoverished by the dis- ease, laid plans to organize the San Francisco Association for the Study and Prevention of Tuberculosis. They decided to start a campaign of "prevention through education," to open a free tuberculosis clinic for the sick poor, to send visiting nurses to those sick at home, and to urge public officials to make better provision for hospitalization of tuberculosis cases. As a beginning, $2,550 of munici- pal funds was provided to erect and equip tents with board floors in which to try the open air treatment on a score of the city's dependent tubercu- losis cases. A newspaper account pub- lished early in April, 1 906, said : "The first open air treatment for consumptives at a public institution west of Denver will begin shortly at the city and county hospital under the direction of Dr. George H. Evans. The first tent was erected yesterday and when the remaining nine are com- pleted twenty patients will be accom- modated. The work is in the nature of an experiment, but great results are expected." This tent colony, on the grounds of the municipal hospital, was fenced with wire. The fence represented the first exercise of public authority in San Francisco for segregation of per- sons dangerously sick with tuberculo- sis from others that might catch the disease from them. Up to that time no attempt to pre- vent the spread of the disease had been made, although it had been known for years that it is communi- cable. There was no law to require reporting of tuberculosis and no ma- chinery for its control existed. Far advanced cases were mingled indis- criminately among patients brought to the hospital with other ailments. A dying consumptive might be sharing his quarters and his eating utensils with patients recovering from other respiratory diseases and thus passing on his disease to those with weakened resistance. Possibly this state of affairs had something to do with the fact that up to 1906 San Francisco had by far the highest tuberculosis death rate of America's ten largest cities. Plans for the campaign against tu- berculosis were completed early in April, 1906. The evening of April 18 was selected for a public meeting at which officers would be chosen and the work formally started. The meeting was not held, for on April 18 came earthquake and fire. In the days that followed, the or- ganizers of the Association had many other tasks and responsibilities that postponed their planned activities against tuberculosis. Bubonic plague broke out in the fall of 1907 and many of them served on the Citizens' Health Committee that raised $152,000 by private subscriptions and worked with public officials against that disease. Early in 1908 plans for a campaign against tuberculosis were taken up again. Organization began at a luncheon meeting over which Mrs. William H. Crocker presided. Other meetings were held at luncheons down town and on a number of evenings at the home of Mrs. John F. Merrill. On June 25, 1908, organization of the Association was completed. The first officers and directors, chosen at this meeting, were : Thomas E. Hayden, President Dr. Herbert C. Moffitt, First Vice-President Mrs. John F. Merrill, Second Vice-President Dr. Rene Bine, Treasurer Dr. William C. Voorsanger, Secretary DIRECTORS J. J. Bakewell, Jr. Mrs. E. L. Baldwin Henry U. Brandenstein Gustave Brenner Dr. Rene Bine Dr. Charles M. Cooper Mrs. William H. Crocker Mrs. S. W. Dennis Dr. George H. Evans Miss Katherine Felton Thomas E. Hayden Dr. A. W. Hewlett Walter Macarthur Miss Laura McKinstry Mrs. John F. Merrill Dr. Herbert C. Moffitt Charles C. Moore Mrs. S. S. Palmer Mrs. Henry Payot Osgood Putnam A. W. Scott, Jr. Dr. Harry M. Sherman Mrs. M. C. Sloss Dr. William C. Voorsanger Thomas E. Hayden served as pres- ident of the Association from its or- ganization until January, 1912. He was succeeded by Jesse W. Lilienthal, who continued as president until his death in June, 1919. Since October, 1919, John S. Drum has been the As- sociation's president. Dr. William C. Voorsanger has been the Association's secretary ever since its organization. The Association was incorporated in 1911. In 1920 its name was short- ened, for convenience, from "The San Francisco Association for the Study and Prevention of Tuberculosis" to "San Francisco Tuberculosis Associa- tion." The Association launched its educational campaign with this dec- laration to a skeptical world : "Tuber- culosis is a preventable and usually a curable disease." It announced that it purposed "to teach all who will learn, how not to get the disease, how not to give the disease and how to get well of it," To this end a free clinic was opened, visiting nurses were sent from house to house, lectures were given, sermons were preached, handbills were circulated, advertisements were posted in street cars, articles were published in newspapers, exhibits of good and bad housing as related to disease were displayed and every means at the com- mand of the Association was used to create an informed public opinion. Ever since its beginning it has been the aim of the Association to bring to bear against tuberculosis every possi- ble influence that may aid toward its final conquest. Aside from its general educational activities the Association undertook to bring about state and county legisla- tion that would give boards of health the legal power and necessary finan- cial appropriations to provide better care for the indigent sick and to take measures for control and prevention of the disease. In its first year the Association, through its committee on legislation, of which Walter Macarthur was chairman, succeeded in getting such legislation through the Senate and Assembly, but it was vetoed by the Governor. In 1909 the Association was successful in having adopted in San Francisco an ordinance in which tuberculosis was officially declared "a communicable disease dangerous to the public health" and the local board ■ of health was empowered to take cer- tain steps to prevent the spread of infection. From its beginning the Association was active in support of building laws that would insure proper space for sunlight and fresh air in the recon- struction of the city. A remarkable decrease in San Francisco's death rate from tuberculosis followed the purg- ing of the city by fire. Many sunless and ill-ventilated old habitations were burned. In the rush of reconstruc- tion many dwellings were erected that would not be permitted under the building laws of today, but in general the new buildings were far superior from a health standpoint to those that they replaced. A tenement house or- dinance that was passed in June, 1907, principally through the efforts of the Telegraph Hill Neighborhood Asso- ciation, was in a large measure re- sponsible for this. To local efforts for better housing, and for inspection of milk, meat and other foodstuffs, all of which have a bearing on the prevention and control of tuberculosis, the Association gave its support. Meanwhile it continued its efforts to have similar action taken by the state. The annual report of the Association for 1911 says: "In February, March and April of 1911 several trips were made to Sacramento by President Thomas Hay den, Dr. William C. Voor Sanger, Dr. R. G. Brodrick and Chairman Macarthur of the legislative commit- tee in the interest of Assembly Bill 821, authorizing the state board of health to make a special investigation into the prevalence of tuberculosis, and of Senate Bill 292, requiring the registration of all cases of tuberculosis, which bills were introduced into the last legislature by this Association/' The work of the Association's com- mittee on legislation eventually led to the shaping of state policies by which many excellent county tuberculosis hospitals have been established in Cali- fornia and maintained at high stand- ard under state supervision and with the aid of a state subsidy. The state board of health, under authority given by one of the bills sponsored by the Association in 1911, appointed a tuberculosis commission of five and an advisory committee of fifty to investigate the prevalence of tuberculosis in California and to rec- ommend ways and means for its con- trol and prevention. Dr. George H. Kress, Los Angeles, was chairman of the commission. Dr. R. G. Brodrick and Miss Katherine C. Felton were San Francisco mem- bers of the commission. Sixteen other San Franciscans served on the advis- ory committee. They were : Rev. Charles F. Aked J. J. Bakewell, Jr. Charles H. Bentley Dr. Philip King Brown Rev. D. O. Crowley Miss Margaret B. Curry Frederick W. Dohrmann Dr. George H. Evans Miss Alice Griffith Mrs. M. W. Kincaid Walter Macarthur Rabbi Martin A. Meyer John I. Nolan Dr. William Ophuls Dr. William C. Voorsanger Frederick S. Withington A thorough study of the tuberculo- sis situation in California was made and a report submitted to the legisla- ture. As a result a state bureau of tuberculosis was created to cope with the disease, legislation enabling coun- ties to combine for the purpose of erecting tuberculosis hospitals was en- acted, state subsidy was provided for county tuberculosis hospitals that could comply with . certain specified standards of care and treatment, and much other legislative action calcu- lated to control and prevent the dis- ease followed in the next few years. The recommendations of the state tuberculosis commission of 1911 in- cluded many things besides free bed care in hospitals and country sanatoria for persons with tuberculosis unable to provide hospital care for them- selves, and free dispensary care for those not in need of hospitalization. The commission also recommended governmental inspection of milk, meat and foodstuffs ; stricter housing laws ; inspection of tenements, factories and lodging houses; regulated hours of labor; public playgrounds and recrea- tion centers; medical inspection of all school children and the teaching of health as a regular part of school work. Great advances along all these lines have been made since that time and all, no doubt, have played a part in 10 the reduction of the tuberculosis death rate that has taken place. Throughout its earlier years finan- cial support for the Association was principally supplied by a compara- tively few persons. The continuous employment of field nurses and main- tenance of clinics was made possible only by large gifts from Mrs. William H. Crocker. San Francisco business firms provided without charge much of the material for constructing and equipping the building on Jackson Street that for many years housed the association's offices and free clinics. Donations that the Association re- ceived were supplemented by the sale of Christmas seals. Mrs. John F. Merrill, one of the organizers of the Association, and also Mrs. Henry Payot, were principally responsible through their management of the sale for developing it into the Association's principal source of funds. Mrs. Wil- liam Haas was another who not only took an active part in the Association's work, but also made large contribu- tions for its financial support. The annual sale of penny seals at Christmas time now supplies the ma- jor part of the Association's funds. The seal sale is one of the Associa- tion's most effective ways of stimulat- ing public interest in the tuberculosis problem. It has also proved to be each year directly responsible for the discovery by the Association of addi- tional cases of tuberculosis, not pre- viously known to physicians or field nurses. In earlier years the seals were sold upon the streets and at public gather- ings by volunteer solicitors. Later the custom of offering the seals by mail was adopted and the sale now is al- most entirely by mail. The funds of the Association are carefully used under direction of an executive council. Until 1928 it met twice each month. It now meets once a month. The books of the Associa- tion are audited each year. The Association maintains an of- fice at 20 Second Street that is open every day except Sunday. Books, mag- azines, pamphlets, posters, lantern slides and motion picture films having to do with tuberculosis, and other health topics, are kept on hand. Some of this material is given away and any of it may be borrowed. Information about tuberculosis, about the work of the Association, and the ways in which its funds are spent will be freely given to anyone. ASSOCIATION HEADQUARTERS 1909-1921 11 Some of the Things That Hare Been Done To Control and Prevent Disease HP HE first tuberculosis clinic was ^ opened by the Association in Jan- uary, 1909. The Telegraph Hill Neighborhood Association provided clinic rooms. Dr. William C. Voor- sanger, Dr. W. R. P. Clark and Dr. James L. Whitney did the medical examining. A few months later the Association completed a building at 1547 Jackson Street for its headquar- ters. Here the major part of the clinic work was carried on until July, 1921, when it was taken under mu- nicipal administration. More than 24,000 men, women and children have been enrolled as new patients in the twenty years the tuberculosis clinics have been in op- eration. In the first six years from 350 to 450 new patients were enrolled each year. In the last six years from 1500 to 2000 new patients have been enrolled annually. When the Association established its first free clinic twenty years ago it met open hostility. Citizens demanded that the clinic be closed by the Board of Supervisors, threats were made to close it by injunction, protests even were made against display of the word "tuberculosis" at the clinic en- trance. In time the purpose of the clinic, and the value of its work, be- came better understood and public feeling about it changed. The number of visits to the clinic made by patients in the first year was about 1600. Attendance has grown until about 6800 visits are now made to the clinics by patients each year for examination and advice. The accompanying chart shows how clinic attendance has increased. A greater increase in recent years would be shown were it not for the fact that the Association has main- tained for the last three years two special clinics at Stanford and Uni- versity of California hospitals in San Francisco for a study of tuberculosis in children. Many children have at- tended these clinics who would other- wise have attended the older clinics for persons of all ages. Attendance at these two special clinics is not in- cluded in the totals from which the chart was drawn. In addition to the work done in clinics the Association has provided tuberculosis examinations for many thousands more in places where men and women work, in public and pri- vate schools and in clubs and com- munity centers. In the last year phy- sicians provided by the Association have examined more than 12,000 per- sons in such places. A field nursing force to seek out new cases and supervise the home care of tuberculosis patients for whom hos- pital provision could not be made was built up by the Association as rapidly as its finances permitted. Efforts to convince the city that tuberculosis is a municipal problem were continued. The president of the Association stated in 1911 : "Much of the work we are doing now ought to be done by the city. One purpose of organizing this society was to lay the foundation for work to go on under city administration." In 1916 three nurses were supplied through municipal funds to carry on tuberculosis field work in connection with the five nurses paid by the Asso- ciation. The city was divided into eight districts and a nurse assigned to each. The annual report of the municipal Board of Health for 1917 says: "For the first time in its history, the city of San Francisco took upon itself the responsibility of grappling with the problem of handling the tu- berculosis situation, the board of su- pervisors in the budget of 1916-17 12 having set aside $5,000 for the estab- lishment of a bureau of tuberculosis." On July 1, 1921, appropriations for the municipal bureau of tubercu- losis were increased so it could take over the clinic and field nursing work. The Association still supplements this work in various ways. At present the municipal bureau of tuberculosis pro- vides ten visiting nurses and the Tu- berculosis Association four. The As- sociation also helps the field nurses keep in touch with patients discharged from the hospital by supplying a part- time clerical assistant. It is not the Association's true func- tion to carry on medical and nursing work that properly should be done by the municipal department of public health, except temporarily such work as cannot be undertaken by the de- partment for lack of funds. The As- sociation's medical and nursing enter- prises are arranged to supplement those of the department and are car- ried on under municipal direction and control. Duplication of effort and expense is avoided. Health work among school children began in a small way in San Fran- cisco in 1908 when the board of su- pervisors gave the health department funds to start one medical inspector and four nurses. From time to time the school inspection staff has been increased. It is not yet of sufficient size to meet adequately the needs of a city in whose public and private schools and kindergartens approxi- mately 100,000 children assemble each school day. In February, 1916, the Association joined with the board of education in establishing an open-air school to provide for children in poor physical condition the close supervision and special care necessary to restore them to vigorous health without interrupt- ing their attendance at school. The board of education provided housing ATTENDANCE AT FREE TUBERCULOSIS CLINICS IN SAN FRANCISCO SINCE THE FIRST CLINIC WAS OPENED BY THE TUBERCULOSIS ASSOCIATION IN JANUARY 1909 *<*»- HALF YEAR JAN1 to JUNE 30 7000 6500 6000 5500 5000 4500 4000 3500 3000 2500 2000 1500 IOOO 500 O 1909 »0 II 12 13 14 IS 16 17 18 19 20 21 21-22 22 23 2W* 2425 2526 2M7 2728 CALENDAR YEARS " FISCAL YEARS ' 13 accommodations and teachers. The Association provided medical and nursing care, meals, cots, blankets and similar equipment. A second open-air school was opened in May, 1919. Two years later ap- propriations for the municipal bureau of tuberculosis were sufficiently en- larged to permit it to undertake, with the board of education, complete su- pervision and support of open-air schools. In 1921 the Association helped the municipal departments of health and education establish health teaching and health supervision classes in San Francisco's elementary public schools. As a beginning, 44,500 children in 93 schools were weighed, measured and given preliminary physical examina- tions. With the co-operation of parents and family physicians, and through free treatments at clinics for those from families financially unable to provide their own medical care, hun- dreds of children have been freed from physical handicaps that tend to undermine health and retard prog- ress in school. Arrangements were made to teach healthful habits of living in all the schools and to provide inexpensive and nutritious luncheons at cost. Health supervision classes were formed for the benefit of children in need of spe- cial attention and instruction to bring them to robust health without inter- ruption of school attendance. The Association provided a number of teachers, doctors and nurses to help carry this additional work through the experimental period. From time to time the regular employes of the departments of health and education took over parts of this work and by July, 1925, all of it. Meanwhile the health department and the directing heads of San Fran- cisco's parochial educational system started similar health work in the parochial schools, which the Associa- tion is aiding them to extend. The value of school health work is not so much in the discovery of stu- dents with active tuberculosis as in the discovery of physical impairments and weaknesses of various kinds that, if permitted to continue, lay a child open to successful attack by tuberculosis in the critical years of early adult life. Tuberculosis kills in San Francisco fewer persons between the ages of 10 and 20 than it kills in any other 10- year age group. But from those in their twenties it takes its heaviest toll, and particularly in the early twenties. The Association believes that an- nual medical inspection of all school children, and particularly of those in the high schools and part-time schools, combined with corrective work, will serve to arm with natural resistance sufficient to carry them safely through adult life, many boys and girls who would otherwise be overcome by tu- berculosis in their twenties. It has therefore supplemented the limited resources of the school medical inspection service by supplying doc- tors and nurses, who work under the direction of the city health officer as members of his school staff. Doctors employed by the Association examined more than 10,000 high school and junior high school students last year. Assistance from the State Bureau of Tuberculosis and the California Tu- berculosis Association made it possible to increase the effectiveness of inspec- tion by use of an x-ray laboratory mounted on a motor truck. X-ray examinations were made of the chests of more than 3,000 students. Search for a quick cure for tuber- culosis goes on continuously in hospi- tals and laboratories throughout the world, still unsuccessfully. Develop- ment of the x-ray as an aid to early discovery of tuberculosis, and im- provements in chest surgery as a means of arresting the disease in cer- tain cases, are advances in medical science, but there is not yet any quick cure, any sure cure, any cheap cure for tuberculosis. Rest, good food, sun- shine, fresh air, a carefully ordered method of life, and patience are re- 14 quired to win back health, once it is lost. The Association has helped to a small extent, when money was avail- able for the purpose, in the search for a cure that will be quicker, surer and less expensive than the long course of sanatorium treatment now required. In 1921 it helped finance at the University of California hospital re- search work by which it was then be- lieved a cure for tuberculosis might be developed from chaulmoogra oil. Careful and thorough experiments proved that this belief was incorrect. At present certain studies with tu- berculin are being carried on in the research department of the University of California hospital. Toward the expense of this work the Association contributed $500. Next to prevention, which is always better and cheaper than cure, early discovery is the most important objec- tive of the campaign against tubercu- losis. Medical authorities say that tuberculosis lasts, on an average, five years. The nearer to the time of be- ginning that the disease is discovered the less difficult it is to check it. It is known that most persons are first infected with tuberculosis in childhood. To study this childhood infection, to determine the frequency with which it occurs in San Francisco among children of various ages, and to de- velop more exact methods of discover- ing and controlling the infection, two free clinics for children from infancy to fifteen years of age have been main- tained by the Association at Univer- sity of California and Stanford hospi- tals for the last three years. Approximately 4,000 children have been enrolled at these clinics. Many were found with tuberculosis and sent to hospitals. Others suspected of hav- ing the disease, or believed likely to get it because of poor physical condi- tion, have been re-examined from time to time and provided with home nurs- ing supervision. Many have been sent to convalescent homes and similar in- stitutions. More than 3,000 x-ray pictures have been taken. From these, and from carefully recorded observations of physicians and nurses employed by the Association, much has been learned to make possible the earlier discovery and more effective treatment of tuber- culosis in children. i r * IT y mi' SCHOOL MEDICAL INSPECTION WITH STETHOSCOPE AND X-RAY 15 More and Better Hospital Care Provided for Victims of the White Plague HP O obtain adequate public care for ^ those with tuberculosis unable to provide for themselves has always been one of the aims of the Associa- tion. Progress in this was particu- larly difficult in early days. The num- ber in need of hospitalization was so great that public officials contended no municipality could raise sufficient money to meet the problem. Public knowledge of and interest in health work had not been developed. Munic- ipal appropriations for public health protection were small. In San Francisco, public officials, harassed by financial difficulties and pressing needs in reconstruction of the city after the disaster of 1906, paid scant attention to the plight of the tuberculous. Their attitude was re- flected in quotations from health de- partment reports of that time: "There seems to be no means of lessening the number of those suffer- ing from this dread disease. It seems as though the federal government should care for this class of patients as their disease is lasting and communi- cable and no municipality should be expected to bear the expense." The same reports contain the in- formation that "an anti-tuberculosis league is trying to combat the inroads of this dread disease." The City and County Hospital, a dilapidated frame structure 35 years old, escaped the great fire of 1906, but at the finish of the campaign against bubonic plague, whose victims it had sheltered, it was torn down and the wreckage was burned. Patients had been moved to a temporary hospi- tal in an old building at the county poor farm in January of 1908. Two months later that building was destroyed by fire. Arrangements were made to scatter the sick poor among private hospitals, the govern- ment hospital at the Presidio and barns at the Ingleside race track. The Associated Charities fitted up one of the barns for a tuberculosis hospital. The municipal appropriation for maintenance amounted to 74 cents per patient per day. Appropriations of other cities at that time were double that amount. TUBERCULOSIS HOSPITAL 1908-1911 The board of health, calling atten- tion in its annual report for 1908 to the need for better quarters for the sick, had this to say of the hospital : "Although everything was done to put the buildings, which formerly were used as stables for race horses, in a habitable condition, naturally the result is not all that could be desired. All the buildings are old and the roofs more or less leaky, which will cause much annoyance in the approaching rainy season. Some of the buildings are open to such an extent that it will be practically impossible to heat them; others again do not provide for suf- ficient ventilation." Many entries similar to the follow- ing appear in the old minute books of the Tuberculosis Association : "Mrs. Henry Payot, Mr. Jesse W. Lilienthal and Dr. R. G. Brodrick were appointed to appear before the board of supervisors and request that the appropriation for maintenance of tuberculosis patients be increased." "Dr. A. H. Giannini and Dr. William C. Voor Sanger were directed to go to Sacramento and urge upon the legislature passage of a bill pro- viding for a state subsidy to county tuberculosis hospitals" 16 From time to time municipal appro- priations for maintenance of tubercu- losis patients were increased. San Francisco now spends more than $3.00 per patient per day. Part of this is provided by state subsidy, which began in July, 1916. The annual re- port of the health department at that time says: "Commencing July 1, 1916, the State subsidized 85 beds in the tuber- culosis hospital at the rate of $3 per week per patient, in consideration of the hospital's complying with certain housing and food regulations. By rea- son of the improvements made, the number of subsidized beds was in- creased from 85 to 100, effective March 1, 1917. The total subsidy for the year amounted to $13,368." Since the beginning of state subsidy a total of approximately $300,000 has been received from this source for maintenance of patients in San Fran- cisco's tuberculosis hospital. In May, 1911, the Association launched a public protest against the miserable conditions under which tu- berculosis patients were compelled to exist in the horse barn hospital. Other agencies joined with it. In July the Association committee directing the campaign reported : "After considerable work a munic- ipal appropriation of $30,000 has been authorized for construction of a lean-to tuberculosis department on San Francisco hospital grounds at Vermont and Twenty-second Streets, same to be completed in 60 days" Seven temporary wooden struc- tures were erected to provide for 150 patients. They were first occupied in the fall of 1911 and continued to serve as the city's tuberculosis hospi- tal until July, 1919. The present hospital was then completed and op- ened for patients. Although built to house 250 patients, it has provided beds for as many as 290 adults at one time. In April, 1927, an addition that houses sixty children was com- pleted. In September, 1927, the Health Farm, a hospital in the coun- try near Redwood City for early cases of tuberculosis, was opened. It houses 40 patients. Construction of the Health Farm hospital was preceded by a long search for the most suitable site in the coun- try near San Francisco. The Health Farm, a partly wooded tract of a lit- tle more than 300 acres, is situated on a sunny slope about 25 miles from San Francisco at an elevation of 600 feet. It overlooks the southern arm of San Francisco Bay and is sheltered by a range of hills that holds back the cold wind and fog from the Pacific Ocean. The Health Farm has about 100 more days of sunshine in a year than are enjoyed by San Francisco. Here exist ideal conditions for res- toration to health and economic use- fulness of many young persons in San Francisco with tuberculosis in its early stages. Lacking suitable care, such cases drift along into the advanced stages of the disease and in the end impose a greater economic burden on TUBERCULOSIS HOSPITAL 1911-1919 17 the community than if sufficient funds were provided to give them promptly institutional care at the time when there is the best opportunity to check their disease. To establish the Health Farm it was necessary to amend the charter of the City and County of San Fran- cisco. The amendment was submitted to the voters in the fall of 1922. It received 88,000 favorable votes and carried by a ratio of A 1 /, votes to 1, the greatest vote of approval given to any of the 53 measures that were on the ballot at that election. It is now planned to double the bed capacity of the Health Farm, bringing it from 40 to 80 beds, as well as to enlarge the main tuberculosis hospital in San Francisco, with funds from a bond issue for health purposes that is to be submitted to the voters in November, 1928. If this plan is ap- proved by the voters, it will make pos- sible the restoration to health of many sufferers from tuberculosis for whom it is not now possible to provide proper care. A vast improvement in tuberculosis hospitals has taken place throughout California since united efforts to con- trol and prevent the disease were started and public interest in the tu- berculosis problem was aroused. The situation that existed until a few years ago is pictured by this quotation from the state tuberculosis commission's final report to the legislature, pub- lished in 1914: "It is doubtful if the county hospi- tals, with a few exceptions, are at this time properly conducted as regards the treatment of tuberculosis. Most of them simply provide a place for advanced cases to die. Some of the counties have wards and separate buildings, specially designed for the treatment of tuberculosis, but in the majority of these places there are ab- solutely no facilities either for treat- ing the patients or for protecting those suffering from other diseases. County sanatoria and hospitals where residents sick with tuberculosis might really have a fair opportunity for restoration of health and usefulness are still in the incipient stage" Of San Francisco's municipal tu- berculosis hospital the report to the legislature said: "In this hospital now most of the patients received are in an advanced stage, and it is too late to do very much for them except to provide sim- ple comforts until such time as they shall die" Happily these conditions have been greatly changed. Since 1919 San Francisco has had a municipal tuber- culosis hospital not excelled by that of any city. Lack of sufficient bed space, however, still hampers the ef- forts of health officials to control the disease. First consideration necessar- ily must be given to those most desper- ately sick. They, of course, are the cases least likely to be cured, but for humane reasons they must be given TUBERCULOSIS HOSPITAL SINCE 1919 18 hospital care first of all. As a result many whose disease is less advanced, and might be quickly checked by prompt hospitalization, must remain on the waiting list with such care as can be given them in clinics and by field nurses. The need for more beds also makes it necessary at times to discharge con- valescents from the hospital, before they are really strong enough to go, in order to provide places for emer- gency cases that must have immediate hospital care. As a result many such discharged convalescents again break down with the disease and again be- come dependent upon the community. It is believed that the additional beds contemplated by the proposed bond issue for health purposes will remedy this situation and stop the great economic loss caused by the re- peated return for hospitalization of persons who under present conditions are required to leave the hospital before their disease is completely arrested. In the last twenty years throughout the United States hospitals for the tuberculous have greatly increased in number and size, and great improve- ments have been made in the type of care provided within the hospitals. In 1908 there were in California 10 institutions for care of the tuber- culous and they provided a total of 465 beds. Now, in 1928, there are more than 50 institutions in Califor- nia for tuberculosis cases and they provide more than 5500 beds. In 1904 when the first directory of tuberculosis hospitals in the United States was published there were about 100 institutions for care of the tuber- culous and they provided fewer than 8000 beds. In 1928 the number of institutions for the tuberculous in the United States had increased to more than 600 and the number of beds to more than 72,000. As more and better hospital care has been provided for persons with tuberculosis there has been a marked decrease in the number of deaths from the disease. THE BEGINNING OF THE HEALTH FARM 19 Tuberculosis Death Rate Now Reduced To Lowest Point on Record ITT is probable that no city ever ex- ^ perienced a quicker reduction in its tuberculosis death rate than the drop in San Francisco's rate immediately after the great fire of 1906. The fire carried on a four-day campaign against tuberculosis that was effective, but it cost more than $500,000,000. Breeding places of the disease were wiped out by the thousand. Outdoor life was suddenly forced upon thou- sands of persons who customarily slept with locked windows and believed that night air was poisonous. The accompanying chart illustrates the number of deaths from tubercu- losis in San Francisco each year since 1900. Note the great drop in the number of deaths that immediately followed the fire of April, 1906. This reduction was only in part caused by the fact that many persons moved from the city temporarily after the fire. The city quickly recovered its former number of inhabitants, and more, but tuberculosis never regained the ground it had lost. For instance, in the census year 1910 San Francisco had about 75,000 more people than when the census of 1900 was taken, but about 250 fewer deaths from tuberculosis. For years before the great fire tuberculosis killed with monotonous regularity about 100 persons every month. Its annual toll was close to 1200 persons. It has never since killed more than 960 in any one year. In 1927 it killed 593. This is the lowest annual mark on record. In comparing the total for 1927 with the number killed each year be- fore the great fire it should be borne in mind also that the city is now twice as large as it was then. The population of San Francisco, as estimated by the Bureau of the Census, the number of deaths from tuberculosis and the death rate per 100,000 of population for each year since 1900 follow: Year Population Deaths Rate 1900 342,782 1132 330 1901 350,913 1161 330 1902 358,420 1142 318 1903 365,927 1208 330 1904 373,434 1151 308 1905 380,941 1175 308 1906 388,448 813 209 1907 395,955 818 206 1908 403,462 856 212 1909 410,969 837 203 1910 418,838 886 211 1911 428,084 809 189 1912 437,330 860 196 1913 446,576 884 198 1914 455,822 959 210 1915 465,068 962 206 1916 474,314 897 189 1917 483,560 854 176 1918 492,806 943 191 1919 502,052 922 183 1920 511,298 682 133 1921 520,544 648 124 1922 529,790 648 122 1923 539,036 680 126 1924 548,282 659 120 1925 557,518 644 115 1926 566,774 611 107 1927 576,020 593 102 It is contended by many persons that the census estimates of popula- tion for recent years are far less than the actual population of San Fran- cisco. If that is true the reduction in the death rate in recent years has been even greater than shown by the fig- ures in this table. For instance, if the rate is computed from the chamber of commerce estimate of population instead of the census estimate, San Francisco's tuberculosis death rate in 1927 was 80 per 100,000 of popula- tion instead of 102. Whether the fire of 1906 was en- tirely responsible for the great reduc- tion in tuberculosis in San Francisco that immediately followed cannot be said with certainty. The fact should not be overlooked that in 1906, as noted elsewhere in this booklet, the open-air treatment of the tuberculous at the county hospital and their segre- gation to prevent the spread of infec- 20 tion among other patients first began. At about this time also impetus was given to various activities calculated to lessen disease, such as the opening of free clinics, the employment of field nurses, medical inspection of school children, municipal inspection and regulation of milk and meat supplies and a widespread campaign of public education about health. An interna- tional congress on tuberculosis was held in Washington, D. C, in 1908, and this did much to increase public interest in the war against disease. Another important influence was the rapid increase in the number of public and private hospitals for the treatment of persons with tuberculosis. Another great decrease in the tu- berlosis death rate took place about 1-920 throughout the United States as well as in San Francisco. Some per- sons say the epidemic of influenza that swept the country in 1918 and 1919 was principally responsible for this drop, believing that influenza killed many persons in 1918 and 1919 who would othenvise have died of tuber- culosis within the next few years. Others attribute the great decrease in the tuberculosis death rate that has taken place in the last eight years to the unusual prosperity of those years. Greater numbers of people get better wages, live in better homes and have better food. There are fewer desper- ately poor people. Hours of labor are less than they used to be. People have more time for rest and recreation. Cheap transportation makes it possible for more people to get out into the sunshine and fresh air, and to get out often. The number of persons that take part in outdoor sports has tre- mendously increased. Various influences, some exerted by natural laws and other directed by man, have contributed to the long- continued decline of tuberculosis. There is no way to measure separately how much each of many influences has accomplished. In California in the last twenty years many changes for the better have come about through legislation that has improved conditions under which the great mass of people work and live. All this has a bearing on the reduction of tuberculosis. 1200 1120 1040 960 880 600 720 640 560 460 400 320 240 160 80 O TUBERCULOSIS DEATHS IN SANTRANCISCO EACH YEAR SINCE 1900 1200 1120 1040 960 880 800 720 640 560 4 80 400 320 240 160 60 o 1900 01 01 03 04 OS 06 07 08 09 19 10 li 31 13 24 2$ 16 17 21 The improvement that has taken place with respect to tuberculosis in San Francisco is characteristic of the change that has taken place through- out the United States, although there has been a far greater decline in the death rate of San Francisco than in the death rate of the United States as a whole. The chart on this page shows how the rate has declined in San Francisco and how it has declined in the whole United States since 1900. The chart is based upon statistics published by the United States Bureau of the Cen- sus. For the United States as a whole there was a slight increase in 1926 over 1925. There was a reduction again in 1927, but the exact figure for the year has not yet been published by the census bureau. The decline in San Francisco from 1905 to 1906 was probably not in fact so extreme as indicated by the chart, for in calculating rates the census bu- reau made no allowance for the tem- porary decrease in San Francisco's population immediately following the earthquake and fire of 1906. It is interesting to note how much greater San Francisco's rate was than the rate for the United States as a whole from 1900 to 1905 and how the rate for San Francisco is now little above that of the rate for the whole United States. As explained previously in this booklet many persons believe the cen- sus bureau greatly underestimates San Francisco's population. If local esti- mates of population are correct, San Francisco's tuberculosis death rate is now less than the rate for the United States as a whole. 1900 01 340 OX 03 04 05 06 07 08 09 igio II 12 13 14 15 16 17 18 19 1920 21 22 23 Z4 25 26 27 340 320 320 300 300 280 \ How tuberculosis death rate \ has declined since 1Q00 280 266 240 \ san Francisco \ ---— . United States 260 240 220 220 200 ...... 180 160 140 200 ieo 160 140 120 **.. 120 IOO 80 *•— —. *"••-. -.. *— MOO 80 eo 60 40 40 20 20 o 1900 01 02. 03 04 o5 06 07 08 09 1910 II 12 13 14 15 16 17 18 19 1920 21 22 I J 24- 25 26 27° 22 < «"|pUBLIC health is purchasable. Within natural limitations a community can determine its own death rate." — Biggs. "HpHREE-FOURTHS of the deaths from tuber- culosis would be avoided if knowledge now existing among well-informed men were applied to a reasonable extent." — From the report of the National Conservation Commission. Press of The Margaret marv morgan Co. s. F.